Performing Biopsies as a General Dentist: Simple Techniques and How To Bill For It

Welcome to The Dr. Phil Klein Dental Podcast. I'm Dr. Phil Klein. In this podcast, we'll answer some common questions about the role of the GP in detecting oral cancer and how GPs can become more proficient in oral cancer screening and biopsy techniques. We'll also talk about how to bill for these life-saving services. Our guest is Dr. Robert Convissar, a general practitioner with over 40 years of clinical experience. In addition to maintaining a private practice in New York City, he also lectures worldwide on laser surgery, biopsy techniques, and infant tongue-tie release. Dr. Convissaris the author of over half a dozen textbooks and well over a dozen peer-reviewed scientific publications. Before we get started, I'd like to mention that Dr. Convissar’s webinar, titled Performing Biopsies as a General Dentist, Simple Techniques and How to Build for It is now available as an on-demand webinar on vivalearning.com. Simply type in the search field Convassar, C-O-N-V-I-S-S-A-R, and you'll see it. It's an excellent webinar for those GPs who are interested in learning more and becoming more proficient in the detection of oral cancer. Dr. Convissar, it's a pleasure to have you on Dental Talk. Great to be here, Phil. Thanks. So to begin this podcast, let's... Talk about the overall cancer exam. What does it look like and how does a dentist perform a thorough oral cancer exam? Well, oral cancer exam is relatively simple. All you need is a regular dental mirror, a piece of gauze, and your eyeballs. That's it. It's just a matter of using your fingers to palpate everything. Take a look. Make sure everything looks pink and healthy. Make sure there are no lumps or bumps. Make sure that everything looks... relatively normal bilaterally, that there's nothing unusual. You then take a piece of gauze, wrap it around the tongue, and just pull the tongue out. The number one site for malignancies in the oral cavity is the lateral border of the tongue. So you just take a piece of gauze, wrap it around the tongue, pull the tongue out as far as you can, move the tongue to the left, move the tongue to the right, check both lateral borders, move it up. check down to the root of the tongue, and that's basically it. If you want to be a little bit fancier, you could get a pharyngeal mirror, which is nothing more than a regular plain old dental mirror with a very, very, very long handle. And what you can do with that is you can hover it not on the palate, that'll make people gag, and not on the tongue, that could make people gag, but you can hold it halfway between the tongue. and the palate and you can look all the way down to the root of the tongue where sometimes malignancies start as well so it's it's not a difficult thing and of course there are adjunctive devices as well such as goggles glasses for oral cancer screening and a bunch of other devices as well So in doing an intraoral exam, the dentist sees something suspicious. And I assume, you know, regular dentists that's out there doing their dental work every day should be able to identify something that looks somewhat different that may be suspicious. Hopefully they'll have that training. What are the steps in determining if something is benign or malignant once that identification process is over? Well, I've developed a little pneumatic device that I use that helps me tremendously. F-I-G-R-U-B, FIGRUB. Doesn't mean anything, but if we take the first letter of each of those, F-I-G-R-U-B, it'll help determine if it's most likely benign or most likely malignant. The good thing about doing oral cancer screenings is the top 23 or 24 types of lesions that a dentist will see are most likely benign. Lichen planus with constriations. ulcerations, abscesses, things like that, the great majority of what we see as GPs is going to be benign. So the odds of seeing something malignant is not all that great. Having said that, you still must do a comprehensive oral exam. So Dr. Convissar, you mentioned an acronym, FIGRUB, correct? F-I-G-R-U-B? Yeah, what do those letters stand for? Okay, these are six qualities. that can determine if a lesion is most likely benign or most likely malignant f for fixed if the lesion is fixed to the underlying tissue uh it's not freely movable it could be malignant if it's freely movable it's it's rubbery and soft it's most likely benign that's f for fixed i indurated if it's hard and indurated hard it is probably malignant If it's not indurated, if it's nice and soft, it's probably benign. G for growth. If it has been growing very slowly, it is most likely benign. If it has grown quickly, it wasn't there a week ago, and it's there now, and it's getting larger, fast growth means it could be malignant. Slow growth could be benign. R for red. Or white or red and white. If a lesion looks red or white or red and white, it could be malignant. If it's not red or white, it could be benign. U for ulcerated. If the lesion is ulcerated, the surface epithelium, the surface mucosa is ulcerated. That could mean that it is malignant. If it's not ulcerated, could be benign. And B for bleeds. If it bleeds easily, It bleeds just by looking at it, bleeds without you poking around at it. It could be malignant. If it doesn't bleed easily, it's benign. Now you have to take fig rub, these six qualifications, with a grain of salt. If I'm looking on somebody's palate and they have a lesion that's fixed and indurated and ulcerated, Well, that's three out of the six qualifications, fixed, indurated, and ulcerated. But if it's on the palate, it may be nothing more than a palatal torus with a pizza burn on it. So once again, you have to take these six qualities and just use it with a little bit of common sense and you should be able to determine. Yeah, I'm sure there are many tumors that are malignant, I should say, that don't bleed, right? That's true also. Yes, yes. So you don't have to have all six of these to determine that it's malignant. If you have three of them, it's a good probability that it's malignant. But once again, you need to know what's normal before you can determine if it's abnormal. So you need to know, is this normal anatomy? Is it a torus? Is it a tuberosity? What is it that we're looking at? rather than, oh, that doesn't look normal. Lots and lots of people have tori. Lots of people have tuberosities that are large and can be ulcerated just because they're chewing on them a lot. So there's a lot of different possibilities when you use fig rub. Just use it with a little bit of common sense. So when doing an intraoral exam, but then to see something suspicious, what are the steps in determining if it's benign or malignant after a full examination? Well, once you do fig rub, fixed, indurated, grows, red, ulcerated, and bleeds easily, you then take a look and see if it's in an area where you feel comfortable performing a biopsy. If it's all the way on the roof of the mouth, on the soft palate or the junction of the soft and hard palate, that may be difficult for a gentleman. practitioner if it's on the buccal mucosa may be easy for a general practitioner so location is is quite important the other important thing is hemostasis if it's in the midline of the palate well there's not a lot of blood vessels there if it is closer to the teeth on the palate, you may have the posterior superior alveolar arterioles and venules there that may cause a little problem with hemostasis. So once again, knowing what's normal is critical before you can decide if it's abnormal and if you feel that you can do a biopsy confidently and confidently. How many GPs do you think are doing their own biopsies of suspicious lesions? The last time I checked with the American Dental Association, because they have all sorts of statistics about that, I believe the figure was something like 17 to 20 percent of GPs perform biopsies, which means more than 80 percent are being referred out to the oral surgeon. If you're trained in biopsy technique, it's really a very, very simple thing to do. Personally, I use a laser. You don't need to use a laser. You can use a 15 blade. You can use a punch. You can use cryosurgery. You can use electrosurgery. It doesn't matter what you can use as long as you are trained. in the modality i've seen plenty of laser harvested biopsies that were beautiful and some that were terrible because the practitioner doesn't know the ins and outs of laser surgery same thing with electrosurgery you use it at too high a setting you could fry the lesion and the pathologist will have a problem so training training training are the three important criteria for deciding if you want to biopsy it and if you feel confident to biopsy it. So what would you recommend a new dentist who's coming into practice on their own to have in their office as far as special equipment regarding doing a biopsy on their own? As far as special equipment, you really don't need anything for a biopsy. like i said 15 blade or a punch lots of dentists have punches these days they'll use punches for any of a dozen different things including uncovering implants or punch is relatively common these days 20 years ago it wasn't 15 blades most every dentist has a pair of ivy scissors many many dentists have lasers these days so i don't want people out there to think oh i've got to buy a whole lot of equipment so you don't need anything aside from some sort of cutting device, like we just mentioned, a suture setup to suture the lesion if it needs suturing. And that's basically it. Everything else you'll get from the oral pathologist. When you call an oral pathology lab, they'll send you the biopsy kit. They'll send you the mailing label. They'll send you the envelope. They'll send you the formalin in the jar. So simple. And I agree. It's important to get the training on how to... do the biopsy to make sure that the pathologist has a specimen that is valuable to them to be able to detect what cells are in there. Frying it beforehand with a laser or electrosurge is not going to be a good thing. The last thing you want to do is have the patient. Yeah. You don't want to call the patient back and say, we need to take another, another specimen. Right. So how do you get paid? So how does, does it work through medical insurance, dental insurance? How does the dental practitioner get paid? This can be a little dicey. Practice is insurance-based. I accept assignment of insurance. But we have to be careful. There are some insurance companies that have decided that the tongue is not part of the mouth. So if I do a biopsy on a tongue, some insurance companies, dental insurance companies, will pay. Others will not. They'll say that's medical. But if I send the patient to an oral maxillofacial surgeon who has the same DDS or DMD degree as I do, they'll get paid for a tongue biopsy. So insurance companies can be a little sketchy. That's why I always make certain before I perform the biopsy that I have my office manager or insurance coordinator call the insurance company, get the name of the person you speak to and say, hey, I'm doing a tongue biopsy. I'm doing a lip biopsy. I'm doing a cheek biopsy. Is this something that will be covered by? dental insurance if I do it. That way there are no surprises. There are some practices that will send it out to medical insurance. The problem these days with medical insurance is that you need to be a participating provider with some medical plans. Once again, it's something that most general practitioners are not doing, but oral maxillofacial surgeons are doing. So this is one of the problems why oral surgeons do more biopsies than GPs. The insurance companies throw up these. barriers in our way to prevent us from giving good patient care. You mentioned lip. And I know tongue, you said, is the most common, the lateral border of the tongue. But I would think the lip is pretty common, too. It's up there on the list. Would you do a biopsy outside of the lip area, the vermilion border, where you would have some aesthetic consequences that you'd have to worry about? Or is that something in your realm? That's something that... would do because i've been doing this for a very long time and i know the modality that i use i use a laser and i know how a laser will work on mucosa versus how a laser will work on a lip but for dentists just starting out whether using a laser once again or electrosurge or a blade or whatever i would say stick to inside the vermilion border do a couple of biopsies from the vermilion border inside cheek, mucosa, wherever, and don't do anything past the vermilion border until you are confident and competent with your choice of cutting device. Okay. And as far as marketing the service, is that valuable to a dentist to make it known that they do this? Or is that something you want to deal with on just a doctor to patient level, just between you and the patient? I think it's critically important to market this. Oral cancer. is the sixth leading cause of death in males in the United States, in cancer deaths. So it's up there. There are more cases of oral cancer than there are of melanoma, of cervical cancer, things like that. So it's an important disease that we need to talk to our patients. about. And of course, thanks to HPV, human papillomavirus, HPV we all know is highly associated with cancers of the female reproductive tract. It is also highly associated with oral cancers as well. You take a look at somebody like Michael Douglas. who ended up with oropharyngeal cancer, and it was a result of an HPV-type lesion. He's not the only one. There are plenty of people that have had HPV-induced oral cancers. Mentioning Michael Douglas, I have to say he's a great, great reference that everybody should invite into their office. Michael Douglas did a PSA, a public service announcement. for the Oral Cancer Foundation. And you can download it from the Oral Cancer Foundation. You can find it on YouTube. And it's something that I would strongly advise people have in their waiting rooms, in their hygiene rooms, put it on an iPad, put it somewhere, and have everybody just listen to the short announcement by Michael Douglas about how serious oral cancer can be and how nobody really knows anything about it. And it's something that a general dentist can and should check on on a regular basis the other important thing is if you look at Gordon Christensen he did an evaluation of various oral cancer detection devices and the statement he made was that oral cancer screening must be part of a routine dental exam and dentists should make certain they discuss it with their patients. So this is something that everybody should be aware of. Everybody should be marketing to their patients. Everybody should be talking to their patients about. And I have a set routine script that I use that works very, very well to convince people to have this oral cancer screening. Yeah. And when it comes to oral detection, as we wrap up this podcast, you mentioned goggles. How does that work, that device? Gockels is a pair of glasses that they look like glasses that you use for your curing light. What they do is they filter out specific wavelengths. So if you have a curing light, you use the curing light, radiate the mouth with the curing light, and the gockels will be able to differentiate between different types of tissues, fast-growing tissue versus regular or slow-growing tissue. Cancers, malignancies. tend to have a higher mitotic activity than normal tissue. So when you put on the goggles and you use your curing light, you can tell there's a difference in the fluorescence of the tissue, which doesn't mean you have cancer. It just means it's something that you must. investigate further, and a biopsy would be a great way to investigate. It's not a bad thing to have in the office, obviously, as an adjunct to early detection. The other good news about using goggles or any of the other devices, there are a bunch of devices out there, is that there is an ADA code where you can get paid for this. It's a diagnostic code. It's in everybody's ADA, CDT book. And I'll tell you my experience practicing in New York City. Some MetLife insurance policies will pay up to $150 on patients 40 years of age and over every 24 months to have an oral cancer screening with this or similar devices. And MetLife isn't the only company. Some guardian insurance company policies pay for it also. Not every policy does, but many policies do. So you're getting paid for... potentially life-saving examination. So it's a wonderful thing to have these devices. Thank you very much, Dr. Convissar. It's great stuff. We really appreciate your input into such an important thing, which is a thorough intraoral exam, screening for cancer. And we look forward to have you on future podcasts soon. Have a great day. Thank you. My pleasure.